A nurse is caring for a client who has a hemoglobin of 10.8 g/dL and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following conditions?
Cellular hypoxia
Fluid retention
Prolonged bleeding
Impaired immunity
The Correct Answer is A
Choice A rationale:
Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.
Here is a detailed explanation of how anemia can lead to cellular hypoxia:
Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.
Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.
Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.
Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.
Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.
Common signs and symptoms of cellular hypoxia:
Fatigue Weakness
Shortness of breath Pale skin
Dizziness Headache Chest pain
Tachycardia (rapid heart rate) Cognitive impairment
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
Here are the steps to calculate the gtt/min for the manual IV infusion:
Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes
Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min
Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is B
Explanation
Choice A rationale:
The spinal cord plays a crucial role in pain transmission, but it does not initiate the afferent pathways. It receives pain signals from nociceptors and relays them to the brain for processing.
The spinal cord is also involved in pain modulation, as it can dampen or amplify pain signals depending on various factors. However, it is not the primary trigger for pain sensation. That role belongs to nociceptors.
Choice B rationale:
Nociceptors are specialized sensory receptors that detect potentially damaging stimuli, such as intense heat, pressure, or chemical irritants.
They are located throughout the body, including the skin, muscles, joints, and internal organs.
When nociceptors are activated, they generate electrical signals that travel along nerve fibers to the spinal cord and brain. This process initiates the afferent pathways, which ultimately lead to the conscious perception of pain.
Nociceptors are essential for protecting the body from harm. They alert us to potential dangers and trigger responses that help us avoid injury or further damage.
Choice C rationale:
Endorphins are natural pain-relieving substances produced by the body. They act on receptors in the brain and spinal cord to reduce pain perception.
However, endorphins do not trigger the afferent pathways. They work by modulating pain signals that have already been initiated by nociceptors.
Choice D rationale:
The cortex is the outer layer of the brain that is responsible for higher-level functions, such as thinking, feeling, and decision- making.
It plays a role in the conscious experience of pain, but it does not trigger the afferent pathways.
The cortex receives pain signals from the spinal cord and processes them, leading to the awareness of pain.
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